English Version | Beyond the mirror

There is an intriguing simplicity in the way Dr. Ana Silva Guerra talks about her career: it is a clarity that is reflected not only in her discourse, but also in her clinical practice, where form is never superimposed on function. Her approach is pragmatic and deeply ethical, the result of solid training and a philosophy that combines aesthetics with functionality. In a career marked by her training at Hospital São José, a demanding environment where she dealt daily with severe trauma and polytraumatized patients, constant contact with delicate situations shaped her vision and sensitivity, teaching her that plastic surgery is much more than aesthetics: it is the art of rebuilding, restoring function and dignity. Her restless spirit led her to expand her horizons across borders, and experiences in countries such as Brazil, Belgium and England opened up new perspectives for her, especially with regard to aesthetic medicine: if there wasn't much training here, it was her curiosity and dedication that led her to develop this aspect of her practice. For more than a decade, she has been combining plastic surgery and aesthetic medicine, treating the patient as a whole, with a rigor that she never abdicates: if functionality is the starting point, aesthetics is not ignored; on the contrary, it is treated with the respect it deserves, integrating naturally into the process of well-being and aging well. And it is precisely this holistic vision that is also evident in his involvement in charitable projects. The development of the Mãos de Esperança (Hands of Hope) project reveals a genuine concern for the social impact of her profession: with the belief that everyone deserves access to decent health care, the doctor has developed pro bono initiatives that offer reconstructive treatments to disabled people, victims of accidents and illnesses that have left deep marks, both physical and emotional. This charitable project is now an essential part of her practice and she has already achieved eleven life-changing achievements.

In a frank and uncomplicated conversation, Dr. Ana Silva Guerra helps us to separate myths from truths in the vast - and not always well understood - universe of aesthetic medicine and plastic surgery. After all, how many of our certainties about procedures stand up to a clinical and realistic look?

What is the biggest myth about aesthetic medicine that people still believe?

One of the biggest myths is that aesthetic medicine can deform the face on the one hand and solve everything on the other. We used to see a lot of fillers in the media, because it was thought that aesthetic medicine could solve everything: that is, instead of removing excess skin - a surgical lift - people would get fillers, because they were so afraid of surgery. This gave aesthetic medicine a very bad name and caused a lot of concern, and I always try to demystify this. I usually explain that my purpose is to age well; we will always age, but doing it well depends on us, and along the way we can have small treatments such as hyaluronic acid, botulinum toxin, biostimulators to take care of the skin. We'll sag, we'll get wrinkles, but it won't be so noticeable, and it'll make us look better when we reach our 50s or 60s. I cannot fill everything with hyaluronic acid because I'm afraid of removing a little bit of skin when it has already accumulated - that's where surgery comes in. I always say, 'From here on in, there's nothing we can do with aesthetic medicine treatments, because we're already running the risk of deforming the face'. There are always two ways to go: do nothing, or consider removing the skin with a lift: improve the neck, the lower third and the eyelid, which is one of the first signs of ageing. There's nothing you can do other than surgery to solve this. So it's the combination of the two points that will make you look good over time, because even if you have surgery and a face lift, there's always room for botox, there's always a need for skin care [...] but everything with a sense of harmony, balance, without exaggeration.

What can we say is realistic to achieve with dermocosmetics alone?

First of all, let's not think that we treat wrinkles with lotions, because the wrinkle exists due to muscle contraction. At first, it's dynamic and over time it will become marked. There is no cream that will correct this, but we do have botulinum toxin which will relax the muscle and it won't contract so intensely. The creams that call themselves anti-wrinkle, their purpose is to moisturize the superficial layers of the skin a little more intensely, which makes the fine lines appear to fade. Now, what do we need to know about our daily routine? Firstly, there's a very important point, which is facial hygiene. I still see a lot of people cleaning their faces with cotton pads, but there's nothing like rinsing your skin with gel [which has to be suitable for your skin type]; washing your face after applying make-up remover is essential. Cottons and wipes only transfer from one side to the other. At night, I generally recommend retinol. Retinol is good because it exfoliates, causing the surface layers of the skin - made up of dead cells - to turn over more quickly. This is good so that small spots disappear more quickly, and the skin looks brighter and better. Retinol helps to boost collagen synthesis and eliminate those superficial layers of cells we no longer care about, as well as penetrating certain active ingredients, such as vitamin C and antioxidants. But it is photosensitive, so anyone who applies retinol needs to apply sun protection. In the morning, we can put on a vitamin C serum, an antioxidant, with ferulic acid or all those active agents that reduce spots and improve the quality of our skin. And why do we put it on in the morning? Because at night we are putting on retinol, and our skin is better able to receive these serums. Sunscreen is crucial: UVA and UVB radiation is responsible for more than 90% of skin damage. [...] We should always carry a stick in the car, and notice that on the left side, for those who drive, we get more spots and wrinkles. People are looking for anti-wrinkle creams and don't talk about sunscreen, and that's wrong: put on all the creams you want, but always put on sunscreen at the end.

What procedures are people asking for most these days?

Most people are looking to improve their face and depending on their age, the condition of their skin and the degree of ageing, they can opt for aesthetic medicine or surgical procedures. There's always a complementarity: I never do just one thing or just the other, except for younger people, where there's no room for surgery. Mostly women come here because they've gained a lot of weight or had pregnancies and are unhappy [with their breasts and abdomen]. The pressure on women is intense: they have to be the perfect wife, they have to work and at the same time be fit. That's not real, it's difficult, apart from the constraints of our lives. I've tried to create ideal conditions in this space to be able to respond to everything: for example, we have endocrinology here, because, with today's stress, there's a lot of thyroid pathology, and we have this more specialized part, as well as another dedicated to weight control, because it's difficult, especially during the menopause. Women are fighting their own hormones, in addition to the psychological changes they're going through. There are also those who come looking for non-invasive treatments for localized fat, for example. I always say that you can do it several times, but in the end you'll want to do liposuction: non-invasive sells very well, but I don't do almost any [non-invasive treatments] because I want to achieve results.

Are people still very afraid in regards to surgery?

Yes, also because of everything you hear, but given that I come from a hospital and have trained with serious pathology, it's inconceivable to think that I'm going to put anyone at risk. I often say that a breast augmentation is a surgery that nobody needs: we're going to go from a time when nothing hurts to a time when everything hurts. Is it worth the risk? [...] Above all, I'm a doctor and I'm here to help. If I set out to do something, I have to make that person better. If I don't think that's going to happen, I won't even touch them. And this clarification is fundamental. [...] People shouldn't have surgery at 40, then there's aesthetic medicine to delay the process. There's a window of time at 55 or 65 when you're still well enough to enjoy the result, you don't have too much pathology, and then it's just maintenance. We have to know how to grow old: it's important that [the surgery] is done in a way that preserves what's natural: I'm not going to do what I like, I'm going to preserve the face and improve the features that have been lost a bit, without changing the essence.

Nowadays, we see rhinomodeling as an alternative to rhinoplasty. What do you think of this?

First of all, I'd like to point out one fact: rhinoplasty is a complicated surgery, not from a technical point of view, but from a psychological point of view. The nose is in the center of the face and we must be very careful to have aligned expectations on the patient's side. We have to understand very well what they want, because when they show me the nose of an actor or actress, it's a sign that something isn't working right. Sometimes it's better not to touch it, because I'll never be able to give them that nose, it won't look right there: I'll use the parameters I know, which are ideal for rhinoplasty, and adapt a nose with mathematical measurements - the nose will be theirs, but a little better. As for rhinomodeling, we have two options: [patients] want a very slight change (and nobody is going to have surgery because of a slight alteration in the cartilage), so we can correct it with hyaluronic acid and it lasts a long time - it's an area that doesn't move much so it lasts more than six months. Or, for those who want a more rounded tip, I'll simulate a bit of that projection with hyaluronic acid, as if it were a preparation for surgery. If they have an enlarged dorsum, with rhinomodelling I can also create two lines and make the area slimmer.

What are the risks of doing these procedures in non-specialized places?

Worldwide, in aesthetic medicine, the nose and the nasolabial fold are the most dangerous areas to inject, and there are many associated cases of blindness and death. If you do it with professionals who are qualified to do it, the risk is small: there is always a danger, but if you do it with someone who doesn't know anything about what they're doing, it's enormous. [...] There are consequences that are reversible, but blindness is very difficult to reverse. I know that people are always looking for the cheapest, and I understand that. But when it comes to our health, that tends not to be a sign of quality, and it's important to look for qualified, trained professionals; of course that will cost more, but there's a much higher safety profile. [...] In these treatments, people get a bit carried away with 'oh, it's just a bit of hyaluronic acid', but it's not... serious consequences can result and we have to look at this as a health aspect. It has to be done well and with quality products, because there's a lot of counterfeiting.

Is it even legal to do these procedures in non-specialized places?

No, in Portugal only doctors can do them. The authorities responsible carry out this supervision, but it must continue to exist.

Is there any new technology worth knowing about?

I'm very skeptical about new technologies, because I think they're often fads. But something that worries me is sagging, and it's something that will accompany us throughout our lives: arms, breasts, belly, thighs, buttocks... who doesn't complain? In the case of the belly and breasts, we've managed to treat them with surgery, but on the arms and thighs it's very annoying, because we end up with scars in [very visible] places that I don't like at all. So I've been looking for a machine to help us tighten the skin, and I have two at the moment: one is more superficial - mainly to maintain the quality of the skin and for texture, such as acne marks and scars. The other, Renuvion, has been around for a while, but in Portugal it's new, and uses plasma energy. In this case, there is a cannula that emits a ray - it has helium inside - and it will shrink what joins the skin to the muscle, promoting retraction. It has spectacular results on the arms, thighs and jowls, without surgery, and can be used everywhere, but those are the best places.

How many sessions are needed?

 Just one. This usually has to be done in the operating room so that the person is comfortable, and because we often associate it with liposuction. But it's only one session, which is very good, and it has great results.

Demystifying popular beauty trends

Lymphatic drainage: Lymphatic drainage is very important, but it should be done by physiotherapists who know how to do manual lymphatic drainage. I think we should all do it, it's excellent and I highly recommend it, even for the lower body: who doesn't have swollen legs? Improving lymph circulation is essential for the immune system.

LED light masks: They can be a complement, but there is little scientific evidence.

Microneedling: Yes, it's good. The technical name is percutaneous collagen induction, and it can bring huge improvements to the body and the quality of our skin. At the same time as improving skin texture, it will also stimulate collagen production. All aggression - as long as it is controlled, of course - brings enormous benefits to the skin, and in this case the micro-needles will aggress the skin in a controlled way and we will respond by producing collagen. This makes the skin more permeable to the introduction of active ingredients [...] and gives it a spectacular glow, without altering the features or expression. It's a bit unpleasant because it's slightly painful and the skin is a bit red for a few days afterwards, but it's spectacular. Morpheus, which is radiofrequency with micro-needles, is also a form of microneedling, except that in addition to the controlled aggression of the skin with needles, we're also introducing radiofrequency. In addition to improving skin texture, we'll promote tightening with energy. I really like it and highly recommend it every three weeks. The chemical peel, controlled and well done, is also excellent.

Collagen supplements: we eat food that enters the mouth and goes through the esophagus, stomach, through a whole process, and then is absorbed in the intestine; what we absorb passes into the blood and goes throughout the body. Collagen is a macromolecule and, in order to be absorbed, it had to be very fragmented. [...] I can take collagen, but I don't know if it's hydrolyzed (fragmented) enough and, if not, it goes straight out. If not, it goes into the blood, and then what? It doesn't have a GPS that tells it to go to the skin: it's going to be distributed throughout all the body's organs and systems, including the skin, but there's no scientific evidence that this is an added value. If we want to increase collagen levels, we go directly to the skin on the spot. So I don't recommend collagen supplements, I recommend multivitamins, possibly some vitamin D that is lacking, but careful nutrition fulfills most of our needs. That's more marketing than anything else.

Baby botox: Yes, baby botox is basically the use of botulinum toxin in a lower concentration. For those who ask me for baby botox - and it's usually done at younger ages - I explain that I use a lower dilution, with less botulinum toxin, and the result will be softer and less long-lasting. What I often see is people who have no idea what they're doing and have Botox that lasts a month and a half; that's not right.

Face taping: We do a lot of taping post-surgery and, when it's well placed, the tapes will keep the tension in the skin and improve the lymphatic drainage in the area. Again, this has to be done by professionals. We have to be critical: it's very easy to be sold things on social media, but we have to think and understand if it's just a fad and if it's not going to harm us. So, taping yes, but done by physiotherapists who know what they're doing: you need to know the direction, the strength and tension, the width of the tapes, the opening...

Under eye fillers: Yes, there's a very big myth: nothing - invasive or not - will change the color of the dark circles. What we can do with hyaluronic acid is reduce the depth of the under eye area, as if we were lifting the skin and making it look lifted, to reduce that cone of shadow. Hyaluronic acid in the under eye is something to be done from year to year, this is a very vascularized area, with very exuberant lymphatic drainage and hyaluronic acid is hydroscopic, that is, it recruits a lot of water, so we have to let it act and not move it any further: the more intervention there is, the more oedema we'll have. [...] In the case of a darker tone, I can improve the quality of that skin so that it's stronger, thicker and so you don't see so much pigmentation underneath. How is this done? Microneedling, for example. [...] Puffiness can be treated with surgery and botulinum toxin can be applied to small, fine wrinkles. When we have too much skin, we'll have to resort to surgery.

Translated from the original in The Eternal Fools' Day issue, published April 2025. For full stories and credits, see the print issue.